Make a claim | Adroit Insurance & Risk

Please select a policy type*

Personal
Business

Please select the claim type*

Property Claim
Motor Vehicle Claim

Motor Vehicle Claim

Insured Name*

Policy Number*

Contact*

Phone*

Email*

Registered for GST

Yes
No

Input Tax Credit entitlement on premium*

Input Tax Credit entitlement on property damaged*

Was the vehicle being used for*

Business Use
Private Use

Property Claim Form

Insured Name*

Policy Number*

Contact*

Phone*

Email*

Registered for GST

Yes
No

Input Tax Credit entitlement on premium*

Input Tax Credit entitlement on property damaged*

When did the loss, theft or damage occur?*

Time*

: HH

MM

Which is:

Occupied by the insured
Unoccupied / Vacant
A holiday home

Please describe what happened*

Vehicle Details

Year*

Make*

Rego*

Model*

Is there any finance owing on the vehicle?*

Yes
No

Are you claiming damage for the vehicle?*

Yes
No

Detailed description of the damage

Was the vehicle towed?*

Yes
No

Has a repair quote been obtained?*

Yes
No

What is the current location of the vehicle?*

Preferred repairer details*

Incident Details

Date:*

Time:*

: HH

MM

Location (street/suburb)*

Please describe what happened in the accident and why it occured. e.g. speed, traffic lights, weather:*

Who does the driver consider is at fault and why?*

Drivers Details

Name*

Contact Phone*

Date of Birth:*

Licence No*

Expiry Date*

Year Licensed*

Licence Type

Learners
Probationary
Full
Class

Did the driver consume alcohol/drugs/medication in the 12 hours prior to the accident?*

Yes
No

Had insurance declined, cancelled or special conditions imposed in the last 5 years?*

Yes
No

Convicted of or had any fines or penalties imposed for any criminal offence?*

Yes
No

Had an accident or made a claim on a motor insurance policy in the last 5 years?*

Yes
No

If YES to any of the above, please provide details*

Third Party Details

Third Party Details Name*

Contact Phone*

Address*

Insurance Company*

Policy/Claim No*

Rego*

Licence No*

Year*

Make*

Model*

Detailed description of the damage*

Police Details (Name/Station/Police Report No.)

Police Details (Name/Station/Police Report No.)*

Witness Details

Witness Details*

Additional Details

Additional Information*

Incident Details

ANY LOSS INVOLVING MALICIOUS DAMAGE, LOST OR STOLEN PROPERTY MUST BE REPORTED TO THE POLICE

Were the premises occupied at time of loss?*

Yes
No

If no, date last occupied*

Time*

: HH

MM

Do you know who is responsible for the loss, theft or damage?

Yes
No

Name

Address

Please detail what has been lost/stolen/damaged and estimate value to repair/replace

Particulars	Amount Claimed

Fusion/Power Surge Claims

Age of Motor

Is the motor under warranty?

Yes
No

Burglary Claim

How was the building entered?

Available security to premises:

Give details of any security improvements taken since the loss:

Police

Station

Report Number

Date Reported

Reporting Officer

If your insurer approves a cash settlement, would you like funds deposited into your bank account?

Yes
No

Bank

BSB

Account Name

Account Number

History

Had insurance declined, cancelled or special conditions imposed in the last 5 years?

Yes
No

Convicted of or had any fines or penalties imposed for any criminal offence?

Yes
No

Had an accident or made a claim on a motor insurance policy in the last 5 years?

Yes
No

If YES to any of the above, please provide details

Declaration

Do you agree to the declarations*

I agree

By submission of this claim for, you acknowledge and accept the following Declarations

Privacy The Privacy Act and the Australian Privacy Principles require your insurer to tell you that they collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to Insurance Reference Services (IRS), etc. or other parties as required by law. By reading and acknowledging the Adroit privacy collection notice you consent for us to proceed with submitting this information to your insurer. You have to right to seek access to your personal information and to correct it at any time. Please contact us on (03) 5244 7813, 8:45am - 5:15pm, Mon-Fri and advise the changes.

Declaration I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the privacy information of all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then the Insurer will be unable to process my/our claim.